Daniel B. Herman

Mortality among homeless shelter residents in New York City.

OBJECTIVES This study examined the rates and predictors of mortality among sheltered homeless men and women in New York City. METHODS Identifying data on a representative sample of shelter residents surveyed in 1987 were matched against national mortality records for 1987 through 1994. Standardized mortality ratios were computed to compare death rates among homeless people with those of the general US and New York City populations. Logistic regression analysis was used to examine predictors of mortality within the homeless sample. RESULTS Age-adjusted death rates of homeless men and women were 4 times those of the general US population and 2 to 3 times those of the general population of New York City. Among homeless men, prior use of injectable drugs, incarceration, and chronic homelessness increased the likelihood of death. CONCLUSIONS For homeless shelter users, chronic homelessness itself compounds the high risk of death associated with disease/disability and intravenous drug use. Interventions must address not only the health conditions of the homeless but also the societal conditions that perpetuate homelessness.

Adverse childhood experiences: are they risk factors for adult homelessness?

OBJECTIVES We tested the hypothesis that adverse childhood experiences are risk factors for adult homelessness. METHODS We interviewed a nationally representative sample of 92 US household members who had previously been homeless and a comparison group of 395 individuals with no prior homelessness. We assessed childhood adversity with a structured protocol that included a previously validated scale indicating lack of care from parents and single-item measures of physical and sexual abuse. RESULTS Lack of care from a parent during childhood sharply increased the likelihood of subsequent homelessness (odds ratio [OR] = 13), as did physical abuse (OR = 16). Sexual abuse during childhood was associated with a nonsignificant trend toward homelessness (OR = 1.7). The risk of subsequent homelessness among individuals who experienced both lack of care and either type of abuse was dramatically increased compared with subjects reporting neither of these adversities (OR = 26). CONCLUSIONS Adverse childhood experiences are powerful risk factors for adult homelessness. Effectively reducing child abuse and neglect may ultimately help prevent critical social problems including homelessness.

Randomized trial of critical time intervention to prevent homelessness after hospital discharge.

OBJECTIVE This study assessed the effectiveness of a previously tested model, critical time intervention (CTI), in producing an enduring reduction in the risk of homelessness for persons with severe mental illness who were discharged from inpatient psychiatric treatment facilities. METHODS A total of 150 previously homeless men and women with severe mental illness and who were discharged from inpatient psychiatric hospitalization to transitional residences on the hospital grounds were randomly assigned to receive usual care or usual care plus CTI at the point of discharge to the community. The nine-month intervention aims to gradually pass responsibility to community sources for providing ongoing support after the intervention ends, thereby leading to a durable reduction in risk of future homelessness. After participants were discharged from the transitional residence (length of stay six to 937 days), their housing status was assessed every six weeks for 18 months via participant self-report collected by interviewers blind to study condition. RESULTS In an intent-to-treat analysis, participants assigned to the CTI group had significantly less homelessness at the end of the follow-up period (the final three six-week intervals) than those assigned to the control group (odds ratio=.22, 95% confidence interval=.06-.88). CONCLUSIONS A relatively brief, focused intervention for persons with severe mental illness led to a reduction in the risk of homelessness that was evident nine months after the intervention ended. This work suggests that targeted, relatively short interventions applied at critical transition points may enhance the efficacy of long-term supports for persons with severe mental illness who are living in the community.

Critical Time Intervention: An Empirically Supported Model for Preventing Homelessness in High Risk Groups

Critical Time Intervention (CTI) is designed to prevent recurrent homelessness among persons with severe mental illness by enhancing continuity of care during the transition from institutional to community living. After providing the background and rationale of CTI, we describe the elements of the model and summarize the status of existing research on its effectiveness. We then briefly illustrate how the CTI model has begun to be adapted and implemented by providing a case example of a homeless woman’s transition from shelter to housing. Finally, we consider plans for the further adaptation, testing and dissemination of CTI in other populations and service delivery settings.

A critical time intervention with mentally ill homeless men: impact on psychiatric symptoms.

We describe the impact of a psychosocial intervention, critical time intervention (CTI), on the cardinal symptom dimensions of schizophrenia, namely negative, positive, and general psychopathology. Ninety-six men with schizophrenia and other psychotic disorders who were discharged from a homeless shelter were randomly assigned to receive either CTI or usual services only. CTI is a time-limited intervention designed to enhance continuity of care during the transition from institution to community. Symptom severity at baseline and at 6 months was assessed using the Positive and Negative Syndrome Scale. Using data on 76 subjects for whom we have complete symptom data, we assessed the impact of CTI on change in symptoms. The results suggest that CTI was associated with a statistically significant decrease in negative symptoms at the 6-month follow-up, reflecting modest clinical improvement. There was no significant effect on positive or general psychopathology symptoms.

Mental Health Needs in New York State Following the September 11th Attacks

In October 2001, the New York State Office of Mental Health and the Department of Epidemiology of the Mailman School of Public Health of Columbia University conducted a rapid assessment of the nature and magnitude of mental health needs in the state resulting from the September 11th terrorist attacks on the World Trade Center. This effort was carried out during a period of great turmoil and uncertaintyas New Yorkers responded to the shocking events of this unprecedented disaster. Using the limited data available at the time, we estimated that over 520,000 persons in New York Cityand the surrounding counties would experience posttraumatic stress disorder resulting from exposure to the attacks, and that more than 129,000 would seek treatment for this disorder during 2002. This assessment is part of an ongoing collaborative process between public and academic partners; the effort is designed to strengthen the capacityof the mental health sytem to respond to current and future terrorism. Estimates from this initial assessment will be refined over time as further data concerning the impact of the September 11th attacks become available.

Capturing intervention effects over time: reanalysis of a critical time intervention for homeless mentally ill men.

OBJECTIVES We analyzed whether a method for identifying latent trajectories--latent class growth analysis (LCGA)--was useful for understanding outcomes for individuals subject to an intervention. METHODS We used LCGA to reanalyze data from a published study of mentally ill homeless men in a critical time intervention (CTI) program. In that study, 96 men leaving a shelters on-site psychiatric program were randomly assigned to experimental and control groups. The former received CTI services and the latter usual services. Each individuals housing circumstances were observed for 18 months after program initiation. Our outcome measure was monthly homelessness: a person was considered homeless in a month if he was homeless for even 1 night that month. RESULTS Four latent classes were found among the control group, but just 3 among the experimental group. Control, but not experimental, group individuals showed a small class of chronically homeless men. The size of the never-homeless class was 19 percentage points larger for the experimental than for the control group. J- and inverted-U-shaped patterns were also found among both groups, but with important differences in timing of patterns. CONCLUSIONS Our results reveal effects not apparent in the original analysis, suggesting that latent class growth models improve intervention evaluation.

The Impact of Critical Time Intervention in Reducing Psychiatric Rehospitalization After Hospital Discharge

OBJECTIVES This study examined the impact of critical time intervention (CTI) in reducing rehospitalization among formerly homeless individuals with severe and persistent mental illness after discharge from inpatient psychiatric treatment. METHODS CTI is a nine-month care coordination intervention designed to support persons with severe mental illness in the transition from institutions to community living. After discharge from inpatient psychiatric treatment, 150 previously homeless men and women were randomly assigned to receive either usual services only or CTI in addition to usual services. Study participants were assessed every six weeks for 18 months after entering the community. RESULTS At the end of the follow-up period, psychiatric rehospitalization was significantly lower for the group assigned to CTI compared with the usual services group (odds ratio=.11, 95% confidence interval=.01-.96). CONCLUSIONS This study demonstrated that CTI, primarily designed to prevent recurrent homelessness, also reduced the occurrence of rehospitalization after discharge.

Trauma Exposure and Posttraumatic Stress Disorder Among Employees of New York City Companies Affected by the September 11, 2001 Attacks on the World Trade Center

OBJECTIVE Several studies have provided prevalence estimates of posttraumatic stress disorder (PTSD) related to the September 11, 2001 (9/11) attacks in broadly affected populations, although without sufficiently addressing qualifying exposures required for assessing PTSD and estimating its prevalence. A premise that people throughout the New York City area were exposed to the attacks on the World Trade Center (WTC) towers and are thus at risk for developing PTSD has important implications for both prevalence estimates and service provision. This premise has not, however, been tested with respect to DSM-IV-TR criteria for PTSD. This study examined associations between geographic distance from the 9/11 attacks on the WTC and reported 9/11 trauma exposures, and the role of specific trauma exposures in the development of PTSD. METHODS Approximately 3 years after the attacks, 379 surviving employees (102 with direct exposures, including 65 in the towers, and 277 with varied exposures) recruited from 8 affected organizations were interviewed using the Diagnostic Interview Schedule/Disaster Supplement and reassessed at 6 years. The estimated closest geographic distance from the WTC towers during the attacks and specific disaster exposures were compared with the development of 9/11-related PTSD as defined by the Diagnostic and Statistical Manual, Fourth Edition, Text Revision. RESULTS The direct exposure zone was largely concentrated within a radius of 0.1 mi and completely contained within 0.75 mi of the towers. PTSD symptom criteria at any time after the disaster were met by 35% of people directly exposed to danger, 20% of those exposed only through witnessed experiences, and 35% of those exposed only through a close associates direct exposure. Outside these exposure groups, few possible sources of exposure were evident among the few who were symptomatic, most of whom had preexisting psychiatric illness. CONCLUSIONS Exposures deserve careful consideration among widely affected populations after large terrorist attacks when conducting clinical assessments, estimating the magnitude of population PTSD burdens, and projecting needs for specific mental health interventions.

Critical Time Intervention: Model Description and Implications for the Significance of Timing in Social Work Interventions.

Relatively little attention has been paid to the dimension of time in the design of social work interventions. Critical time intervention (CTI), an empirically supported psychosocial intervention intended to reduce the risk of homelessness by enhancing continuity of support for individuals with severe mental illness (SMI) during the transition from institutions to community living, is a model that was explicitly developed to address a timing-specific need. After describing the model and summarizing research that supports its effectiveness, this article considers examples of other time-sensitive interventions in social work and related fields and speculates on some potential advantages to such strategies. Further attention to various dimensions of timing in the design and evaluation of social work interventions is warranted.